For the new study, researchers at the Mayo Clinic analyzed health statistics collected by the World Health Organization. The resource included data from 183 countries, allowing the researchers to compare countries’ life expectancy and healthspans, which are calculated by years of life weighted by health status.
Longer, but not better
Overall, the researchers saw lifespan-healthspan gaps grow around the world, with the average gap rising from 8.5 years in 2000 to 9.6 years in 2019. Global life expectancy rose 6.5 years, to about 73 years, while healthspans only rose 5.4 years in that time, to around 63 years.
But the US was a notable outlier, with its gap growing from 10.9 years to 12.4 years, a 29 percent higher gap than the global mean.
The gap was most notable for women—a trend seen around the world. Between 2000 and 2019, US women saw their life expectancy rise 1.5 years, from 79.2 to 80.7 years, but they saw no change in their healthspans. Women’s lifespan-healthspan gap rose from 12.2 years to 13.7 years. For US men, life expectancy rose 2.2 years, from 74.1 to 76.3 years, and their healthspans also increased 0.6 years. Their lifespan-healthspan gap in 2019 was 11.1 years, 2.6 years shorter than women’s.
The conditions most responsible for US disease burden included mental and substance use disorders, plus musculoskeletal diseases. For women, the biggest contributors were musculoskeletal, genitourinary, and neurological diseases.
While the US presented the most extreme example, the researchers note that the global trends seem to present a “disease paradox whereby reduced acute mortality exposes survivors to an increased burden of chronic disease.”
Enlarge/ Dental students, working as volunteers, attend to patients at a Remote Area Medical (RAM) mobile dental and medical clinic on October 7, 2023 in Grundy, Virginia. More than a thousand people were expected to seek free dental, medical and vision care at the two-day event in the rural and financially struggling area of western Virginia.
In the 1960s and 1970s, people who lived in rural America fared a little better than their urban counterparts. The rate of deaths from all causes was a tad lower outside of metropolitan areas. In the 1980s, though, things evened out, and in the early 1990s, a gap emerged, with rural areas seeing higher death rates—and the gap has been growing ever since. By 1999, the gap was 6 percent. In 2019, just before the pandemic struck, the gap was over 20 percent.
While this news might not be surprising to anyone following mortality trends, a recent analysis by the Department of Agriculture’s Economic Research Service drilled down further, finding a yet more alarming chasm in the urban-rural divide. The report focused in on a key indicator of population health: mortality among prime working-age adults (people ages 25 to 54) and only their natural-cause mortality (NCM) rates—deaths among 100,000 residents from chronic and acute diseases—clearing away external causes of death, including suicides, drug overdoses, violence, and accidents. On this metric, rural areas saw dramatically worsening trends compared with urban populations.
Enlarge/ Change in age-adjusted, prime working-age, external- and natural-cause mortality rates for metro and nonmetro areas, 1999–2001 to 2017–2019.
The federal researchers compared NCM rates of prime working-age adults in two three-year periods: 1999 to 2001, and 2017 to 2019. In 1999, the NCM rate in 25- to 54-year-olds in rural areas was 6 percent higher than the NCM rate of this age group in urban areas. In 2019, the gap had grown to a whopping 43 percent. In fact, prime working-age adults in rural areas was the only age group in the US that saw an increased NCM rate in this time period. In urban areas, working-age adults’ NCM rate declined.
Broken down further, the researchers found that non-Hispanic White people in rural areas had the largest NCM rate increases when compared to their urban counterparts. Among just rural residents, American Indian and Alaska Native (AIAN) and non-Hispanic White people registered the largest increases between the two time periods. In both groups, women had the largest increases. Regionally, rural residents in the South had the highest NCM rate, with the rural residents in the Northeast maintaining the lowest rate. But again, across all regions, women saw larger increases than men.
Age-adjusted prime working-age natural-cause mortality rates, metro and nonmetro areas, 1999–2019.
Change in natural-cause, crude mortality rates by 5-year age cohorts for metro and nonmetro areas, 1999–2001 to 2017–2019.
Among all rural working-age residents, the leading natural causes of death were cancer and heart disease—which was true among urban residents as well. But, in rural residents, these conditions had significantly higher mortality rates than what was seen in urban residents. In 2019, women in rural areas had a mortality rate from heart disease that was 69 percent higher than their urban counterparts, for example. Otherwise, lung disease- and hepatitis-related mortality saw the largest increases in prevalence in rural residents compared with urban peers. Breaking causes down by gender, rural working-age women saw a 313 percent increase in mortality from pregnancy-related conditions between the study’s two time periods, the largest increase of the mortality causes. For rural working-age men, the largest increase was seen from hypertension-related deaths, with a 132 percent increase between the two time periods.
Enlarge/ Nonmetro age-adjusted, prime working-age mortality rates by sex for 15 leading natural causes of death, 1999–2001 and 2017–2019, as percent above or below corresponding metro rates.
The study, which drew from CDC death certificate and epidemiological data, did not explore the reasons for the increases. But, there are a number of plausible factors, the authors note. Rural areas have higher rates of poverty, which contributes to poor health outcomes and higher probabilities of death from chronic diseases. Rural areas also have differences in health behaviors compared with urban areas, including higher incidences of smoking and obesity. Further, rural areas have less access to health care and fewer health care resources. Both rural hospital closures and physician shortages in rural areas have been of growing concern among health experts, the researchers note. Last, some of the states with higher rural mortality rates, particularly those in the South, have failed to implement Medicaid expansions under the 2010 Affordable Care Act, which could help improve health care access and, thus, mortality rates among rural residents.
